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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION 0 Installation © Repair © 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 101698923 1-13-2021 <br /> Facility Name <br /> H&S Energy # 3035 <br /> Facility Address City ZIP Code <br /> 192 Lathrop Road Lathrop 95330 <br /> [2, SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Walton Engineering, Inc. 916-372-1888 <br /> Mailing Address <br /> P.O. Box 1025, West Sacramento, CA 95691 <br /> Service Technician Performing Test <br /> Anthony Reyes <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number ICC Expiration Date <br /> 8293772 9-2-22 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root Level 4 #845115 1-17-2021 <br /> VMI Leak Detection #3752 6-10-2021 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the monitoring system is operational in accordance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documentation is attached; and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> Anthony Reyes 1-13-2021 <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />